Seven healthcare questions the candidates aren’t answering

Hillary Clinton is quick to tout that she will defend the Affordable Care Act (ACA) and build on it to slow the growth of out-of-pocket healthcare costs while Donald Trump vows to repeal the ACA and have a series of reforms ready for implementation that follow free-market principles.

But when taking a closer look at their proposals, Clinton and Trump are keeping mum about some healthcare issues, and that’s raising some critical questions. Managed Healthcare Executive asked industry experts to comment on what topics presidential candidates are being quiet about, and why they suspect they’re not talking about them.

Gerald Friedman, PhD, professor of economics, University of Massachusetts at Amherst, Amherst, Massachusetts: Most of the increases in U.S. healthcare spending over the last 45 years have been for the price of services rather than the quantity of services consumed. But neither candidate is talking about how their proposal would slow excess inflation.

Even though rising prices burden a great majority of the population who pays for healthcare, the candidates may be keeping this hush-hush because rising prices generate income for those who work in the healthcare sector or own assets employed there. Both parties have large and powerful constituencies who fear that their incomes will fall, or at least grow more slowly, if healthcare inflation is contained. Currently, the ACA does little or nothing to contain healthcare inflation-which threatens to swallow the entire economy.

Friedman: Unless some way is found to lower the cost of providing healthcare, extending coverage to more Americans or improving health insurance coverage for those who are already insured would require additional resources from either higher taxes or increased premium prices. Politicians, therefore, fear that proposing coverage expansions or improvements will leave them vulnerable to attack either for proposing tax increases or for proposing premium increases for those who already have coverage. Greater efficiency in delivery would lessen the burden, which is the idea behind proposals for single-payer systems, but these encounter resistance from those who fear losing income from their existing position in the inefficient healthcare system.

Tom Miller, JD, resident fellow, American Enterprise Institute, Washington, DC: If Clinton were to actually do this, it would require another set of trade-offs. By lowering out-of-pocket costs, more people will be insured and an increase in the healthcare services that people demand and consume will ensue. Consequently, there will be increased pressure on premiums and tax subsidies to subsidize them, as well as to the direct costs of payments to reduce out-of-pocket costs.

On the flip side, low-income individuals who have employer-based plans will want assistance with their own rising out-of-pocket costs as well. But Clinton hasn’t stretched her sensitivity to these workers’ needs or indicated how far her generosity will go. I believe Clinton is keeping quiet on this subject because as a presidential candidate, you want to appear to be dispensing someone else’s money, rather than insisting on more sacrifice or increasing visible costs. She has promised to finance some of this proposal by saying that she will increase taxes on wealthy, upper income individuals-but hasn’t offered further answers.

Miller: The 19 states that have yet to expand Medicaid under the ACA have indicated that they want another type of Medicaid program. But even though the Obama administration has made some modest offers in terms of private insurance-like expansions, it has generally held the line on what Republican governors and state legislators prefer, in terms of larger premium payments by Medicaid beneficiaries, additional exposure to out-of-pocket costs, and some soft type of work requirements.

If all of these things were offered to Republican red states resisting Medicaid, you could expect more of them to take on Medicaid expansion. But that would run counter to some core supporters of the ACA’s plans for Medicaid and the base of Clinton’s supporters. I think the reality is that there won’t be many new incentives for Republican states to come on board.

Miller: When asked, Trump says that it’s the job of Congress to flesh out a more detailed agenda for healthcare policy. He exhibits a “wait and see” and “I’ll probably do what they recommend” type of attitude. This is a change in the tone and style of Trump, a take-charge business executive who usually knows what he wants to do and won’t be silenced or talked down to.

I believe Trump is doing this to hide his lack of investment in any type of healthcare policy development. Furthermore, it allows him to seem like he’s open to a wider range of possibilities without having to think through them. He maximizes flexibility with less accountability.

James Knickman, PhD, professor of health affairs at New York University’s Wagner School, New York, New York: I think Trump will probably not answer this question in any great detail because there is no consensus among Republicans around an alternative plan that would be acceptable to people currently covered by the ACA’s insurance policies.

It makes sense for Trump to be vague about this topic since taking away benefits or making coverage more expensive (in terms of out-of-pocket costs) or less comprehensive will be unpopular among groups Trump needs to support him. Finally, it has worked for the Republicans to broadly denounce Obamacare without giving a detailed alternative.

Miller: While on the campaign trail, Trump has been contrary to some leading Republican policymakers regarding Medicare by being very protective of Medicare beneficiaries’ current-law benefits. Furthermore, he hasn’t mentioned any pressing need to trim them. This is most likely due to the fact that many of his supporters are older Americans and he doesn’t want to change the underlying fabric of what they’re accustomed to.

He wants to reassure them that they won’t have a major disruption in their lives (such as Medicare being restructured substantially) because his other proposals will work. Basically, it’s short-term reassurance while dodging a pretty significant policy issue along the way.

Miller: Trump has mentioned that he would consider extending the ability to deduct health insurance premiums to all individuals, not just business owners. But he’s never said why he prefers a deduction over a tax credit, which tends to be what most Republicans prefer. For individuals in the upper income tax brackets, this may be more than ample. But that’s not true of many low-income people who wouldn’t glean much benefit from a deduction compared to a tax credit.

I think this proposal isn’t well developed or thought out; it indicates a limited vocabulary and understanding of the issues and a limited interest in discussing it further. Since these are not the type of issues that are driving Trump’s campaign, that’s probably why he isn’t spending much time and verbiage on them.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.